New York Client Services (800) 447-5816 fax: (212) 689-9532 PATIENT LAST ___________________ FIRST __________________ MIDDLE _____________ PATIENT 1A DIAGNOSTIC www.integratedoncology.com Highlighted fields are required. Male Female Date of Birth _______ / _______ / _______ ___________________________________________________________________________ Social Security # _____________________________________________________________ City ____________________________________ State _____ Zip ____________________ Lab # ______________________________ Hospital # ______________________________ 1B 1A Address ___________________________________________________________________ Home Phone _________________________ Work Phone ____________________________ CLIENT Referring Physician __________________________________________________________ Treating Physician __________________________________ Phone # ___________________ Referring Physician Phone/pager _________________________________________________ NPI # ______________________ Taxonomy # (NPI Specialty Code) _____________________ Physician/Authorized Signature _______________________________________________________ SPECIMEN AND CLINICAL INFORMATION Specimen Information TESTS AND SERVICES, CONTINUED Molar Pregnancy Hospital status when sample collected: Inpatient Outpatient Non-hospital DNA Ploidy/S-Phase & p57 (IHC) DNA Ploidy/S-Phase If diploid, reflex to p57 (IHC) Body Site/ ID#(s): ________________________ Descriptor: _______________________________ Collection Date: ____________ Time: ____________ Send Date: ___________________ Lymph Node and Bone Marrow Micrometastases Detection NOTE: If multiple blocks are submitted, the best block will be selected. Paraffin Block: (attach H&E with each submitted block) Formalin Other: _________ Required for Breast Cancer: Time to Tissue Fixation:_________ Tissue Fixation Time: _________ Integrated Oncology pathologist will select antibodies (range 1–4 per block) that are medically necessary depending on the tumor type: Breast Melanoma Neuroblastoma Other: ___________________________ Slides __________________ Smears ______________ Bone Marrow _____________ Peripheral Blood/Stem Cell Product_________________ Urine: Voided Urine ________ Bladder Washing_______ Wet Tissue Return Material To: Ordering Client Other: Name/Address (indicate below) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Clinical Information-Diagnosis/Signs/Symptoms in ICD-CM format in effect at Date of Service (Highest Speciﬁcity Required) _________________________________________________________________________ _________________________________________________________________________ Clinical Data: (attach clinical history and pathology reports) TESTS AND SERVICES UroVysion® FISH UroVysion® FISH (MD Review) UroVysion® FISH (PhD Review) Urine Collection Method: Voided Catherized Bladder Wash Infectious Agents (IHC) Adeno CMV H. pylori HSV EBV (LMP1) Parvovirus* HBcAg HBsAg P. carinii TOXO HCAg VZV In Situ Hybridization (ISH) EBV (EBER) PML (JC) HPV Tissue Testing HPV Screen HPV Subtype Only KAPPA LAMBDA HPV if Screen Positive, do Subtype (6/11, 16/18, 31/33) HPV Screen & Subtype Tumor Analysis Immunohistochemical tumor analysis with professional interpretation. Integrated Oncology pathologist will select antibodies (range 1–25) that are medically necessary depending on the diagnosis under consideration: Lymphoma vs. reactive hyperplasia Acute leukemia Adenocarcinoma vs. mesothelioma Bladder vs. prostate carcinoma Carcinoma of unknown primary site Carcinoma vs. melanoma Germ cell tumor GIST Hepatoma/cholangio vs. met. carcinoma Hodgkin vs. NHL Lung vs. breast Lymphoma phenotype Lymphoma vs. carcinoma Molar vs. non-molar pregnancy Neuroendocrine neoplasm Paget’s disease vs. melanoma vs. SqCC Pituitary neoplasm Plasma cell neoplasm Prostate carcinoma vs. adenosis Small cell vs. non-small cell carcinoma Small round cell tumor (e.g., Ewing’s, PNET) Soft tissue tumor SqCC vs. melanoma vs. AFX Squamous cell vs. adenocarcinoma of lung Undifferentiated tumor Consultative Services (Send pathology report) Pathology consultation and report on referred material requiring slide preparation Pathology consultation and report on referred slides IHC staining with brief summary interpretation Technical component (antibody stain) only Individual Antibodies Specify: (The most current Antibody Library is available at www.integratedoncology.com/ab) _________________________________________________________________________ _________________________________________________________________________ Provisional/Differential Diagnosis(es): _______________________________________________ *Investigational Use Only. UroVysion® is a registered trademark of Abbott Laboratories. Integrated Oncology is a brand used by both Accupath Diagnostic Laboratories, Inc. and Esoterix Generic Laboratories, LLC, wholly-owned subsidiaries of Laboratory Corporation of America® Holdings. BILLING INFORMATION INTEGRATED ONCOLOGY INTERNAL USE ONLY BC/BS HMO PPO Indemnity Network Medicaid Medicare Medical Group/IPA Hospital/Facility Bill #______________ Self-Pay Billing Information Attached (Please include a copy of insurance card or face sheet.) Do not attach credit card information to this form. Insurance Company Name ____________________________________________________ Policy # _____________________________ Group # _____________________________ Relation to Insured: Self Spouse Child Other ____________ Patient Signature _________________________________________ Date ________________ © 2014 Laboratory Corporation of America® Holdings. All rights reserved. By signing this form, I hereby authorize Laboratory Corporation of America® Holdings (LCAH), its subsidiaries and afﬁliated companies, to furnish my designated insurance carrier the information on this form if necessary for reimbursement. I also authorize beneﬁts to be payable to LCAH. I understand that I am responsible for any amounts not paid by insurance for reasons including, but not limited to, non-covered and non-authorized services. I permit a copy of this authorization to be used in place of the original. onc-166-V6-0214 1B Determining Necessity of Advance Beneficiary Notice of Noncoverage (ABN) Completion* 1. Diagnose. Determine your patient’s diagnosis. 2. Document. Write the diagnosis code(s) on the front of this requisition. 3. Verify. Determine if the laboratory test(s) ordered for the patient is subject to the Local Coverage Determination or National Coverage Determination. This information can be located in the policies published by Medicare Administrative Contractor (MAC), CMS, or the “Documenting Medical Necessity of Laboratory Services” booklet provided by your LabCorp representative. 4. Review. If the diagnosis code for your patient does not meet the medical necessity requirements set forth by Medicare or the test is being performed more frequently than Medicare allows, an ABN should be completed. *An ABN should be completed for all tests that are considered investigational (experimental or for research use) by Medicare. B2A How to Complete an Advance Beneficiary Notice of Noncoverage (ABN) Medicare is very specific in requiring that all of the information included on the ABN must be completed. Additionally, LabCorp requests that the specimen number or bar code label be included on the form. To be valid, an ABN must: 1. 2. 3. 4. 5. 6. Be executed on the CMS approved ABN form (CMS-R-131). Identify the Medicare Part B Beneficiary, using the name as it appears on the patient’s red, white, and blue Medicare card. Indicate the test(s)/procedure(s) which may be denied within the relevant reason column. Include an estimated cost for the test(s)/procedures(s) subject to the ABN. Have “Option 1”,“Option 2”, or “Option 3” designated by the beneficiary. Be signed and dated by the beneficiary or his/her representative prior to the service being rendered. Integrated Oncology is a brand used by both Accupath Diagnostic Laboratories, Inc. and Esoterix Genetic Laboratories, LLC, wholly-owned subsidiaries of Laboratory Corporation of America® Holdings. ©2014 copyright Laboratory Corporation of America® Holdings. All rights reserved. ONC 166-V6-02172014